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The report provides an overview of the work of the MNSI programme during 2023/24. It sets out the activities carried out by the investigation team since October 2023 when it transitioned to be hosted by the Care Quality Commission (CQC). It also details their plans and priorities for the year ahead.
Sandy Lewis, Programme Director of the Maternity and Newborn Safety Investigation Programme, said:
“Our annual report shines a light on the work we have done in 2023/24 and highlights our plans for the future as we move into 2025.
“The personalisation of maternity care to tackle health inequalities needs to be at the forefront of maternity practice to ensure safe outcomes for all mothers and birthing people. Over the past year, we have worked to improve communication between maternity teams, women/birthing people and families detailed in our blog and through our family and staff information videos. Using our Family Inclusivity toolkit we have now gathered two years of data which helps ensure we are inclusive in how we work with families during our investigations.
“There are significant differences in outcomes for black / ethnic minority women/ birthing people and their babies. Going forward, we will continue to push for the prioritisation of personalised care, including continuing to highlight the importance of equitable outcomes. MNSI is developing a detailed understanding of the factors that support and promote health equity. Staff training sessions have helped us to further explore inclusivity in our work and with the development of our new Health Equity Assessment and Resource Toolkit (HEART) we will ensure health equity factors are systematically considered in every investigation.
“MNSI’s thematic learning provides a unique and holistic view of maternity care in England. We have used these to strengthen our investigation processes, and reports, and have collaborated with other organisations to share our learning and influence the system wide changes which are needed.
“Each family we speak to shares their experience with our team and we aim to provide them with answers to their questions though our investigation process. We repeatedly hear their hope that no other family goes through what they have experienced, but acknowledge this remains an ambition within maternity care in England which is yet to be achieved. Taking the action required to ensure that everyone receives safe, personalised maternity care must therefore be prioritised and sustained. We are committed to playing our part in the system-wide change which is needed to turn this ambition into reality
“Ensuring safe care across maternity services for women / birthing people and their babies remains a system-wide priority. We will continue to build on our priorities and work with families, our staff, and the wider maternity system to strive for safe and equitable care.”
Minister for Women’s Health Baroness Gillian Merron said:
“There are unacceptable inequalities in maternity care across the country.
“This government is working to make sure all women and their babies receive safe, personalised and compassionate care, regardless of their background or ethnicity.
“We will learn lessons from recent investigations, and the work undertaken by the MNSI is an important part of improving services.”
Read our report here.
